Provider Demographics
NPI:1528272259
Name:WILCKEN, WAYNE A (MS)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:A
Last Name:WILCKEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E MALONEY AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5024
Mailing Address - Country:US
Mailing Address - Phone:505-863-3377
Mailing Address - Fax:505-722-5622
Practice Address - Street 1:2025 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4803
Practice Address - Country:US
Practice Address - Phone:505-863-3828
Practice Address - Fax:505-863-6612
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health